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(Insurance Carrier) Employment Standards Administration
Office of Workers' Compensation Programs
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Division of Longshore and Harbor Workers' Compensation >>
An insurance carrier's authorization to write insurance for the payment of compensation under the Longshore and OMB No. 1215-0204
Harbor Workers' Compensation Act, 33 USC 901-945, or any of its extensions, may be suspended or revoked if this Exp Date: 09/30/2010
agreement and undertaking form is not executed and returned to the Office of Workers' Compensation Programs
(30 USC 932; 20 C.F.R. 703.213) on request and/or whenever a security deposit is required. The Off ice will use the
information collected to assure the carrier's prompt payment of compensation, medical services and supplies, and any
other obligations it has under these statutes. Furnishing this information is mandatory. (20 CFR 703.205).
Note: persons are not required to respond to this collection of information unless it displays a currently valid OMB
control number.
Having applied for and received authorization from the Office of Workers' Compensation Programs (OWCP) to write insurance under the statutes indicated
above, WE UNDERTAKE AND AGREE TO THE FOLLOWING CONDITIONS ON SUCH AUTHORIZATION:
1. We grant to OWCP a security interest in the collateral described below to secure our liability for payment of all compensation, medical services and
supplies, other expenses, and any other obligations due under the Longshore and Harbor Workers' Compensation Act, 33 USC 901-945, and its extensions.
2. We have delivered the indemnity bonds and letters of credit described in section one to OWCP. We have deposited any negotiable securities described in
section one with a Federal Reserve Bank or the Treasurer of the United States in accordance with 20 CFR 703.207 and 703.208 and make the deposited
securities subject to OWCP's control.
3. In the event we renew, replace or increase this collateral, it will be subject to the terms of this Agreement and Undertaking, including the security interest
granted in section one.
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these
estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor,
Division of Longshore and Harbor Workers' Compensation, Room C-4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
Form LS-275(IC)
April 2004
(2) OMB No. 1215-0204
<< Exp Date: 09/30/2010
4. We authorize OWCP to bring suit under any indemnity bond, draw upon any letters of credit or seize any negotiable securities, collect the interest and
principal, and sell or otherwise liquidate the negotiable securities or any part thereof, when, in OWCP's opinion we -
a) Default on any of our obligations under the Longshore and Harbor Workers' Compensation Act or its extensions;
b) Fail to renew any deposited letter of credit or substitute acceptable securities in its place;
c) Fail to renew any deposited negotiable securities at maturity or substitute acceptable securities in their place; or
d) Have state insolvency proceedings initiated against us.
e) Fail to comply with any of the terms of this Agreement and Undertaking.
5. This agreement incorporates the regulations governing insurance carriers and their deposit of security promulgated by the Department of Labor, including any
modifications the Department makes from time to time. We agree to comply with these regulations.
6. We will comply with OWCP's orders requiring deposits of additional security, proof and verification of our financial condition, statements of our unsecured
obligations under the Longshore Act and its extensions, statements of the status of all outstanding claims, and any other orders concerning our authorization to
write insurance within the time specified in any notice OWCP delivers to us at our last reported mailing address.
7. If we fail to comply with any applicable statutory or regulatory provision, the terms of this Agreement and Undertaking, or any lawful order or communication
from OWCP, we consent to have OWCP suspend or revoke our certificate of authority to write insurance for the payment of compensation under the Longshore
and Harbor Workers' Compensation Act and its extensions.
Signed at
this day of 20 By
Title
STATE OF
County of
, to me known, or being by me duly sworn did depose and say that he/she
STATE OF
County of
STATE OF
County of